Association of race and receipt of regional anesthesia for hip fracture surgery.

BACKGROUND: There is evidence suggesting clinical benefits of regional anesthesia use in the setting of hip fracture repair, including reduced risk of death, deep vein thrombosis, pulmonary complications and myocardial infarction. Thought the literature is mixed, the use of regional anesthesia in hip fracture surgery has not been studied for racial differences. We examined the association of race with neuraxial anesthesia and regional blocks in patients undergoing hip fracture surgery. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program, we identified patients ≥18 years old who were either white, black or Asian and underwent hip fracture surgery from 2014 to 2020. We reported unadjusted estimates of both regional and neuraxial anesthesia use by race and examined sociodemographic characteristics and health status differences. Two separate multivariable logistic regression models were employed to investigate the association of race with the receipt of (1) neuraxial anesthesia and (2) regional block (ie, peripheral nerve blocks, fascial plane blocks). RESULTS: There were 104,949 patients who underwent hip fracture surgery, of whom 16,400 (15.6%) received a neuraxial anesthetic and 6264 (5.9%) received a regional block. On multivariable logistic regression analysis, compared with white patients, black patients (OR 0.67, 99% CI 0.59 to 0.75, p<0.001) had decreased odds, while Asian patients (OR 2.04, 99% CI 1.84 to 2.26, p<0.001) had increased odds for receipt of neuraxial anesthesia as a primary anesthetic. Black race (OR 1.35, 99% CI 1.17 to 1.55, p<0.001) was associated with increased odds for receiving a regional block compared with white patients. CONCLUSIONS: The study suggests that racial differences exist with the utilization of regional anesthesia for hip fracture surgery. While the results of this study should not be taken as evidence for healthcare disparities, it could be used to support hypotheses for future studies that aim to investigate causes of disparities and corresponding patient outcomes.

Preoperative Ultrasound-guided Percutaneous Cryoneurolysis for the Treatment of Pain after Mastectomy: A Randomized, Participant- and Observer-masked, Sham-controlled Study.

BACKGROUND: Ultrasound-guided percutaneous cryoneurolysis is an analgesic technique in which a percutaneous probe is used to reversibly ablate a peripheral nerve(s) using exceptionally low temperature, and has yet to be evaluated with randomized, controlled trials. Pain after mastectomy can be difficult to treat, and the authors hypothesized that the severity of surgically related pain would be lower on postoperative day 2 with the addition of cryoanalgesia compared with patients receiving solely standard-of-care treatment. METHODS: Preoperatively, participants at one enrolling center received a single injection of ropivacaine, 0.5%, paravertebral nerve block at T3 or T4, and perineural catheter. Participants subsequently underwent an active or sham ultrasound-guided percutaneous cryoneurolysis procedure of the ipsilateral T2 to T5 intercostal nerves in a randomized, patient- and observer-masked fashion. Participants all received a continuous paravertebral block with ropivacaine, 0.2%, until the early morning of discharge (usually postoperative day 2). The primary endpoint was the average pain level measured using a 0 to 10 numeric rating scale the afternoon of postoperative day 2. Participants were followed for 1 yr. RESULTS: On postoperative day 2, participants who had received active cryoneurolysis (n = 31) had a median [interquartile range] pain score of 0 [0 to 1.4] versus 3.0 [2.0 to 5.0] in patients given sham (n = 29): difference -2.5 (97.5% CI, -3.5 to -1.5), P < 0.001. There was evidence of superior analgesia through month 12. During the first 3 weeks, cryoneurolysis lowered cumulative opioid use by 98%, with the active group using 1.5 [0 to 14] mg of oxycodone compared with 72 [20 to 120] mg in the sham group (P < 0.001). No oral analgesics were required by any patient between months 1 and 12. After 1 yr chronic pain had developed in 1 (3%) active compared with 5 (17%) sham participants (P < 0.001). CONCLUSIONS: Percutaneous cryoneurolysis markedly improved analgesia without systemic side effects or complications after mastectomy.

Basal Infusion versus Automated Boluses and a Delayed Start Timer for "Continuous" Sciatic Nerve Blocks after Ambulatory Foot and Ankle Surgery: A Randomized Clinical Trial.

BACKGROUND: The common technique using a basal infusion for an ambulatory continuous peripheral nerve blocks frequently results in exhaustion of the local anesthetic reservoir before resolution of surgical pain. This study was designed to improve and prolong analgesia by delaying initiation using an integrated timer and delivering a lower hourly volume of local anesthetic as automated boluses. The hypothesis was that compared with a traditional continuous infusion, ropivacaine administered with automated boluses at a lower dose and 5-h delay would (1) provide at least noninferior analgesia (difference in average pain no greater than 1.7 points) while both techniques were functioning (average pain score day after surgery) and (2) result in a longer duration (dual primary outcomes). METHODS: Participants (n = 70) undergoing foot or ankle surgery with a popliteal-sciatic catheter received an injection of ropivacaine 0.5% with epinephrine (20 ml) and then were randomized to receive ropivacaine (0.2%) either as continuous infusion (6 ml/h) initiated before discharge or as automated boluses (8 ml every 2 h) initiated 5 h after discharge using a timer. Both groups could self-deliver supplemental boluses (4 ml, lockout 30 min); participants and outcome assessors were blinded to randomization. All randomized participants were included in the data analysis. RESULTS: The day after surgery, participants with automated boluses had a median [interquartile range] pain score of 0.0 [0.0 to 3.0] versus 3.0 [1.8 to 4.8] for the continuous infusion group, with an odds ratio of 3.1 (95% CI, 1.23 to 7.84; P = 0.033) adjusting for body mass index. Reservoir exhaustion in the automated boluses group occurred after a median [interquartile range] of 119 h [109 to 125] versus 74 h [57 to 80] for the continuous infusion group (difference of 47 h; 95% CI, 38 to 55; P < 0.001 adjusting for body mass index). CONCLUSIONS: For popliteal-sciatic catheters, replacing a continuous infusion initiated before discharge with automated boluses and a start-delay timer resulted in better analgesia and longer infusion duration.